The most glaring self-inflicted wound from Donald Trump’s first term in office was his decision in 2017 to let Paul Ryan and other traditional Republicans push him into a futile war to repeal the Affordable Care Act. From Ryan’s perspective, the decision made perfect sense: He and his allies despised the welfare state in general and the ACA in particular, and saw Trump’s presidency as a final chance to destroy the hated law before its roots grew too deep.
From Trump’s perspective, the move was a fiasco. By dint of the threat to repeal it and take health insurance from millions of Americans, the ACA became more popular. The repeal effort exposed the hollowness of his grand promises to give everybody “terrific” insurance, and drove a midterm-election backlash that handed Democrats control of the House of Representatives.
Eight years on, Trump has plainly failed to learn his lesson.
[Annie Lowrey: How are we still fighting about Obamacare?]
His signature One Big Beautiful Bill Act, signed into law over the summer, already wreaks havoc on the country’s health-care system by gutting Medicaid; it’s expected to eliminate coverage for about 7.5 million people by 2034. The legislation also failed to extend pandemic-era subsidies, which are set to expire at the end of the year, for health insurance bought through ACA marketplaces. Without these subsidies, premiums will spike for about 20 million Americans—many of them small-business owners and self-employed workers—in January. Republicans in Congress have refused to add these subsidies to their budget bill, and congressional Democrats refuse to pass a budget without these subsidies. This is the main reason for the federal-government shutdown, now entering its fifth week.
The 2018 elections reflected public anger over the Republican Party’s efforts to make health care less affordable for millions of Americans. In 2026 and 2028, Republicans will face an electorate that is already experiencing the surging costs and loss of coverage that was merely hypothetical in 2018. But instead of trying to contain this catastrophe, Trump is doing nothing.
Health care is not a hill on which Trump is willing to die. He detests Barack Obama and delighted in the prospect of eliminating his predecessor’s signature domestic-policy legacy, but his goal in 2017 wasn’t to make health insurance impossibly unaffordable for Americans. He either believed Republicans’ propaganda that Obamacare was such a “trainwreck” that they could easily write a better law, or somehow believed he could simply lure Democrats to the negotiating table for a new plan. His failure was humiliating and politically costly.
The politics of rolling back Obamacare have not improved since then. Nearly 80 percent of the public wants to extend the ACA subsidies that are set to end.
Trump himself at least seems to grasp the risks, and has sought to position himself as a problem-solver on the issue. “I’d like to see a deal made for great health care,” he told reporters earlier this month. “Yeah, I want to see great health; I’m a Republican, but I want to see health care, but much more so than the Democrats.” The president has long recognized the Democratic Party’s advantage on social-insurance programs and has tried to rhetorically co-opt it. But the populist slogans don’t help if people are actually losing their health coverage or paying way more for it, both of which are slated to occur on his watch.
Why, then, is Trump back on this hill?
One possible reason is that Trump blames the shortcomings of his first term almost entirely on his enemies: the media, the “deep state,” and the disloyal members of his first administration who refused to follow his most authoritarian impulses. His second term has focused, with chilling success, on knocking down these obstacles. He has intimidated the media into more favorable coverage, purged the bureaucracy, and staffed his administration with loyalists who won’t question the moral or legal basis for his orders.
That doesn’t mean Trump has no regrets over his ill-fated attempt to repeal Obamacare. But his singular focus on crushing enemies and compelling loyalty at least suggests a lack of attention to other causes of his first-term struggles.
A second explanation is that Republicans in Congress are still too obsessed with rolling back Obamacare to worry about or even acknowledge the political damage they are inflicting on their party—and their president.
“Premiums are going up because health care costs are going up. Because Obamacare is a disaster,” insists Senator Rick Scott, in defiance of projections that the withdrawal of subsidies is what will cause premiums to skyrocket. “At least among Republicans, there’s a growing sense that just maintaining the status quo is very destructive,” says Brian Blase, the president of the right-wing Paragon Health Institute. Blase has been busily publishing papers purporting to show that throwing people off Medicaid somehow won’t make them less healthy and that eliminating insurance subsidies harms only insurers, not people.
[David Frum: The shutdown is a knife at a gun fight]
The anti-government wing of the Republican Party harbors an aversion to social welfare that’s so deep-seated, the GOP doesn’t seem to mind the political risks.
In this case, it seems that Trump’s generalized animosity for the opposing party has overwhelmed his political survival instinct. The president probably doesn’t want to throw Americans off of their health insurance, and he certainly doesn’t want masses of angry, uninsured voters flooding the polls next year. But cutting a deal to preserve these ACA subsidies would mean angering Republicans who suck up to him and handing Democrats a win. That, of course, is a nonstarter. He’d clearly prefer to drift through a government shutdown and sleepwalk into a political disaster that, when it strikes, will seem quite familiar.
